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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 27 | Issue 4
Page Nos. 151-221

Online since Thursday, September 26, 2019

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ORIGINAL ARTICLES  

Pedicle lengthening with traction vasculogenesis: Axial and perforator abdominal island flap model in rat p. 151
Cagil Meric Erenoglu, Yigit Ozer Tiftikcioglu, Bilgen Katipoglu Erenoglu
DOI:10.4103/tjps.tjps_56_18  
Background: Functional vessel elongation is possible with traction vasculogenesis technique. This study questions the effect of traction on pedicle length and flap viability of rat abdominal superficial epigastric and cephalic epigastric perforator flaps. Method: 28 Wistar-Albino rats were divided into 4 groups as superficial epigastric flap control and traction groups and cephalic epigastric perforator flap control and experiment groups. 1 mm daily traction was applied for 10 days to traction subgroups. On the 10th day pedicle length was measured and flaps were raised. 7 days after viable flap areas were measured. Statistical analysis was done. Results: In both superficial epigastric flap and cephalic epigastric perforator flap groups, pedicle length was found to be higher in traction group and flap viability was found to be higher in control groups. No relation was found between pedicle length and flap viability. Discussion: As a novel technique traction vasculogenesis may be applied to flap pedicles for elongation. This elongation process, not surprisingly may reduce the viable flap surface. However, traction vasculogenesis seems promising for functional elongation of axial and perforator flap pedicles under optimal conditions.
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Combined use of ischemic preconditioning and postconditioning in a skin flap model in rats p. 156
Asim Uslu, Osman Koray Coskunfirat
DOI:10.4103/tjps.tjps_70_18  
Purpose: Reperfusion injury (RI) by abrupt restoration of circulation after prolonged ischemia remains an unsolved problem in reconstructive microsurgery. We hypothesized that the combination of ischemic preconditioning (IPreC) and ischemic postconditioning (IPostC) would result in additional preservation of epigastric skin flaps in rats after the ischemic period. Materials and Methods: We used epigastric artery skin flaps measuring 6 cm × 3 cm in 40 Wistar rats. The animals were allocated randomly into four groups: (1) Control, (2) IPreC, (3) IPostC, and (4) IPreC + IPostC group. Flap viability was assessed 1 week after the surgical procedure, and surviving flap area was recorded as a percentage of the whole flap area.Results: Animals in the IPreC, IPostC, and IPreC + IPostC groups showed significantly smaller areas of flap necrosis than those in the control group (P = 0.001). Statistical analyses indicated significant differences between the IPreC group and IPostC group (P = 0.008). However, there were no significant differences between the IPreC group and IPreC + IPostC group (P = 0.453) or between the IPostC group and the IPreC + IPostC group (P = 0.141). Conclusions: IPreC and IPostC showed protective effects against ischemia-reperfusion injury in the epigastric skin flap model. IPostC showed a greater protective effect than IPostC. The combination of preconditioning and postconditioning provided no additional benefit over either intervention performed alone in the skin flap model.
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Clinical experience with hair transplantation for secondary cicatricial alopecias p. 160
Ekrem Civas, Hasan Mete Aksoy, Berna Aksoy, Muhitdin Eski
DOI:10.4103/tjps.tjps_79_18  
Background: Hair transplantation for the treatment of secondary cicatricial alopecia has recently become a more widely used technique. Objective: The aims of this study were to evaluate the results of use of hair transplantation surgery in patients with secondary cicatricial alopecia, to compare the results of the procedure with regard to different etiologies and to evaluate patient satisfaction. Patients and Methods: Forty-five patients with a definitive clinical diagnosis of secondary cicatricial alopecia were included in this retrospective study. Patients' characteristics were obtained retrospectively from medical records. The percentage of amelioration of cicatricial alopecia and patient satisfaction was obtained by interviewing patients. Results: Thirty-nine patients (86.7%) were satisfied and very satisfied with the procedure. While all patients who underwent hair transplantation for the treatment of facial cicatricial alopecic areas were satisfied, patients with hypertrophic scars were not satisfied significantly. Patient satisfaction was correlated to the percentage of amelioration of cicatricial alopecia. While patients with permanent alopecia as a result of developmental defects were satisfied the most, patients with postoperative and posttraumatic scars were satisfied the least. There was no difference between two different hair transplantation methods with regard to patient satisfaction. Conclusion: Hair transplantation done directly into scar tissue could be the first line treatment in selected cases with secondary cicatricial alopecia as this method is less traumatic and easier to perform in comparison with other surgical treatment methods.
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Perforator pedicled propeller flap: A reliable coverage of wounds around ankle p. 167
Mohd Altaf Mir, Shahab Faria Shahabuddin, Dinesh Kumar
DOI:10.4103/tjps.tjps_85_18  
Background: This study aimed to determine the reliability of perforator pedicled propeller flap for coverage of wounds around the ankle. Materials and Methods: This was a prospective study undertaken between September 2017 and November 2018 in the Division of Plastic and Reconstructive Surgery of our institution. Patients with soft-tissue defect of the ankle referred from the Division of Orthopedic Surgery were included. Those with a scarring in the region of calf in the area of proposed flap were excluded. A detailed history and examination were recorded. A complete blood count, kidney and liver function tests, coagulation profile, and hepatitis B and C and human immunodeficiency viral marker testing were performed following informed consent. Anteroposterior and lateral radiographs of the ankle were taken in all cases. Perforator pedicled propeller flaps were raised in all patients for coverage of soft-tissue defects around the ankle. All patients were followed up regularly. Results: Ten patients with soft-tissue defect around the ankle were referred to our division from the Division of Orthopedic Surgery or admitted through the outpatient department of the Division of Plastic and Reconstructive Surgery of our institution. Eight patients were male and two were female, with the age ranging from 10 to 50 years. The mean operation time was 58 min. Size of the flap varied from 21 cm × 8 cm (168 cm2) to 8 cm × 5 cm (40 cm2). Flaps were rotated through 110°–180°. Out of ten flaps, eight flaps survived completely without any complications. Partial flap loss was found in one patient (10%), marginal flap necrosis in one patient (10%), and none of the flap was lost completely. Thus, the overall success rate of perforator pedicled propeller flap in our study observed was 80%. Conclusion: The perforator-based propeller flap is a versatile and reliable flap for the coverage of soft-tissue defects around the ankle because its vascularity is predictable.
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Free muscle sparing vertical rectus abdominis myocutaneous flap p. 172
Said Algan, Onder Tan, Kerem Yilmaz, Harun Karaduman
DOI:10.4103/tjps.tjps_92_18  
Introduction: Abdominal region is a unique donor area in the reconstructive surgery to provide numerous flaps. The aim of this study is to show effectivity of the free vertical rectus abdominis muscle (VRAM) flap in the complex wounds reconstruction without damaging integrity of the rectus abdominis muscle and sacrificing the opposite deep inferior epigastric artery. Materials and Methods: The study population was composed of all patients who applied to our department for evaluation and management of the complex wounds reconstruction with the free muscle sparing (MS) vertical rectus abdominis flap, between September 2011 and October 2015. Results: We utilized the free MS vertical rectus abdominis flap to closure complex wounds in seven patients (6 males and 1 female) in our department. Etiologies were malign skin tumors, amputation stump, unstable scar, and crush injury in three, two, one, and one patients, respectively. All MS vertical rectus abdominis flaps survived completely. A hematoma developed in the recipient site in one case, and it was immediately evacuated without any problem. Conclusions: Free MS vertical rectus abdominis flap is a quite easy and reliable flap to harvest from abdominal wall, reducing the possibility of bulging or hernia formation with less morbidity of the donor site.
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Evaluation of serum chitinase-3-like protein 1, pentraxin-3, and neutrophil gelatinase-associated lipocalin levels in diabetic foot cases p. 176
Soysal Bas, Mustafa Durgun, Huriye Erbak Yilmaz, Bilge Birlik, Mubin Hosnuter
DOI:10.4103/tjps.tjps_96_18  
Introduction: Diabetic foot is a chronic metabolic disease requiring a long duration of treatment and hospitalization in advanced stages. It requires a multidisciplinary approach to the different clinical presentations of the disease that complicate the process. In this study, the effects of serum chitinase-3-like protein 1 (YKL-40), pentraxin-3 (PTX-3), and neutrophil gelatinase-associated lipocalin (NGAL) levels on the prognosis of diabetic foot in different stages were evaluated. Subjects and Methods: A total of 65 patients with diabetes, and 13 healthy controls were included in the study. Wagner stage 0–1 patients were classified as mild disease (n = 26), Wagner stage 2–3 patients were classified as moderate disease (n = 26), and Wagner Stage 4 patients were classified as severe disease (n = 13). Venous blood was taken from the patients, and serum C-reactive protein, erythrocyte sedimentation rate, hemoglobin A1c, YKL-40, PTX-3, and NGAL levels were evaluated. In addition, the relationship between lower extremity vascular status and the markers was investigated. Results: YKL-40 was significantly higher in the severe disease group, PTX-3 was significantly higher in the moderate disease group, and NGAL was significantly higher in the mild disease group. In addition, YKL-40 and PTX-3 levels were found to be high in patients with arterial and venous insufficiency, but this was not observed for NGAL. Conclusions: High levels of serum YKL-40 are associated with advanced stage disease with atherosclerotic process at the forefront, high PTX-3 levels are associated with moderate stage disease with a high level of infection findings, and high NGAL levels are associated with the mild stage of diabetic foot.
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The suprapubic deepithelialized inferiorly based random flap designed to fill the tissue deficiency at supraumbilical area to prevent the concave deformity in abdominoplasty p. 182
Aret Cerci Ozkan, Burcak Tumerdem Ulug
DOI:10.4103/tjps.tjps_98_18  
Introduction: The most critical tissue in abdominoplasty is the midsagittal part of the supraumbilical region with the highest risk of hemodynamic disturbance. Here, the skin is also thinner compared to the neighboring lateral tissues. This may result in postoperative suprapubic depression. Methods: An easy technique is designed to prevent this suprapubic depression. While making the transverse incision, deepithelialized suprapubic flap is kept in place attached to the suprapubic region. The medial supraumbilical deficient tissue is brought down with the abdominoplasty flap and lowered over the deepithelialized suprapubic flap. Results: Follow-up with the patients is between 1 month and 2 years. We have no longer observed any concave deformity. Discussion: Another technique described in the literature designed to prevent the concave deformity is deepithelization of the tongue of tissue projecting from the lower end of the abdominal flap and folding this back to double up the thickness of fat in this area. Nevertheless, the median distal end of the abdominal flap is hemodynamically the poorest part of the flap. Preparing deepithelialized tongue and folding it back raises the vascular insufficiency risk. Suturing the upper edge and the sides of the supraumbilical flap to deep tissues of the abdominal flap distribute the tissue tension to deeper parts, thus reduce the incision tension with reduced scar tension at the midline. Conclusion: The suprapubic random flap is an assurance for prevention of concave deformity and helps to reduce the tension of transverse incision at the midline, thus may reduce the risk of scar formation.
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The versatile use of fasciocutaneous flaps in coverage of extensive soft tissue defects p. 187
Ayhan Okumus
DOI:10.4103/tjps.tjps_100_18  
Background: Coverage of large soft tissue defects has always been difficult. Despite an increase in free flap options and many of combinations, it is still a big problem to repair large defects in some patients. In this study, repair of large defects with random fasciocutaneous flaps prepared from adjacent regions to the defect has been evaluated in functional and esthetic terms, especially in cases where microsurgery methods cannot be implemented or do not suffice. Patients and Methods: Ten patients' large soft tissue defects in different regions were repaired with random fasciocutaneous flaps. Average defect size was 15.2 cm × 18.3 cm, and defects were covered with random flaps with an average size of 14.8 cm × 28.1 cm. Average operation duration and average hospital stay were measured at 2.7 h and 2.2 days, respectively. Results: Patients were followed for 6 months on average. Complications such as flap loss, bleeding, or infection were not encountered in any patient at an early or late stages. Recovery of donor sites was evaluated unproblematic, and esthetic appearance was regarded acceptable. Conclusion: Fasciocutaneous flaps neighboring the defect can be prepared in larger dimensions compared to their alternatives, and they can cover the defect with less problems. Producing quite successful results is highly possible, especially in cases where the use of free and axial flaps is inappropriate. With the rapid development in microsurgery, many flap alternatives have emerged for the coverage of basic or complicated defects. However, random fasciocutaneous flaps have to be kept in mind as they are more basic and often have the potential to produce better and more effective results than these methods.
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Safe and easy way to reconstruct pressure ulcers: Gluteal artery perforator flaps p. 193
Burak Yasar, Cagdas Duru, Hasan Murat Ergani, Ahmet Kaplan, Murat Igde, Ramazan Erkin Unlu
DOI:10.4103/tjps.tjps_102_18  
Introduction: Pressure ulcers continue to be a reconstructive challenge due to the growing number of patients under risk. Frail nature of the affected patient makes this problem even more complicated. Commonly pressure ulcers are reconstructed with random pattern flaps or musculocutaneous flaps. With the emergence of the perforator concept and expanding knowledge in the vascularity of the gluteal integument, gluteal artery perforator flaps became popular in reconstructing pressure ulcers. In this study, we aimed to review the technical tips to improve clinical outcomes of superior gluteal artery perforator and ınferior gluteal artery perforator flaps in the light of our clinical experience. Materials and Methods: Between 2015 and 2018, nine patients with pressure ulcers in the sacral and ischial regions were reconstructed with gluteal artery perforator flaps. Anatomical landmarks were marked, and Doppler ultrasound was also used to identify individual perforators. The subfascial dissection was opted, and skin island was inseted resembling an advancement pattern to prevent peforator kinking and to include maximum number of perforators. Results: All flaps survived, seroma was seen in two patients, and two of the patients had wound dehiscence at donor site. Conclusions: In the era of perforator flaps, with their safe anatomical basis, less morbidity and versatility in design we offer gluteal artery perforator flaps as a reliable alternative in reconstructing pressure ulcers.
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A randomized clinical trial on efficacy of respiration after rhinoplasty: Comparison between spreader grafts and cartilage flaps p. 199
Ezzatollah Rezaei, Arash Beiraghi-Toosi, Ali Parand, Saeedeh Hajebi Khaniki, Yavar Shams Hojjati
DOI:10.4103/tjps.tjps_1_19  
Introduction: Nowadays, in rhinoplasty procedures, different types of cartilage grafts and flaps are being used routinely and proper use of these methods can improve the outcome of this procedure efficiently. In the present study, we are going to compare the efficacy of spreader grafts and cartilage flaps in preventing complications of rhinoplasty such as respiratory distress. Materials and Methods: In a randomized, single-blind clinical trial, 30 patients who referred to our hospital (Ghaem Hospital in Mashhad) for elective rhinoplasty in 2015 were evaluated and followed for 3 months after the surgery. 15 patients underwent rhinoplasty in which spreader grafts were used, and for the others, upper lateral cartilage flaps were used as autospreader flaps. The results of rhinomechanism achieved from rhinomanometer were measured before and 3 months after the surgery. The right and left nasal airflow and airways resistance index were evaluated based on Pascal per milliliter per second. Data were analyzed using SPSS 16.0 software and P < 0.05 considered as statistically significant. Results: The mean age of patients in spreader graft and autospreader flap groups was 23.13 ± 5.11 and 26.73 ± 6.05 years, respectively, and was not significantly different. In both groups, the ratio of female-to-male was 11/4. Mean of nasal airflow and airways resistance both in inspiration and expiration did not differ significantly after surgery between the groups. Left nasal airflow in inspiration (P = 0.025) and right nasal airway resistance in expiration (P = 0.04) decreased significantly after the surgery in comparison to before it in spreader graft group, while changes in rhinomanometry indices in autospreader flap were not significant. Conclusion: Both techniques can be used to keep the inner valve diameter in the normal range and for treatment of internal valve stenosis. Moreover, both techniques are useful in protecting and creating the dorsal esthetic lines.
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Biological reconstruction of the bone defects with free fibula flap after resections of extremity located bone tumors: Clinical and radiological short-term results p. 204
Onur Basci, Bulent Erol
DOI:10.4103/tjps.tjps_72_19  
Background: Recently, limb salvage surgery is a preferred method in orthopedic oncology and extremity-located bone tumors treated by limb salvage surgery have a 90%–95% success rate. The aim of the study is functional and radiological evaluations of the undergone biological reconstruction with free fibula flap (FFF) after tumor surgery and the effects of the defect size on the functional results. Subjects and Methods: Between 2005 and 2010, 13 patients (7M/6F) who underwent limb salvage surgery for benign/malignant bone tumors were included in study. Diagnoses included five osteosarcomas, six Ewing's sarcomas, one high-grade chondrosarcoma, and one aneurysmal bone cyst. Diaphyseal and metaphyseal regions of femur (7), humerus (3), tibia (2), and radius (1) were reconstructed. FFF was combined with a strut femoral allograft in seven cases. Postoperatively, partial weight-bearing allowed at postoperative 3 month and increased gradually. The mean follow-up was 25 months (12–60) and evaluated by extremity function scoring of Musculoskeletal Tumor Society (MSTS) and radiologically. Results: On the 6th month, in 92.3% of patients (12/13), evident union, and on the 12th month, in all of the patients, evident union and bone flap hypertrophy were observed. The mean MSTS score was measured 77.58% (46.66–100). As the resection size increased, the MSTS scores were significantly decreased (P = 0.027); as the bone flap size increased, there were relatively low MSTS scores (P = 0.440). On the patients without bone flap hypertrophy on 6th month, the bone flap size was measured relatively higher (P = 0.069) and the operation duration was relatively higher (P = 0.100). As the operation duration increased, there were relatively lower MSTS scores (P = 0.062). In cases where allograft and VFG combined (7/9 patients) had higher MSTS scores than the ones, only FFF was used (P = 0.621). Conclusions: Limb salvage surgery improves the life quality without worsening the prognosis and is a method that should be preferred. The biologic reconstruction of the defects with FFF, following extremity located musculoskeletal tumor resections have positive effects on functional outcomes.
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CASE REPORTS Top

Use of avulsed skin flap as donor site for reconstruction of total forearm skin avulsion injuries p. 211
Burkay Akduman, Galip Gencay Ustun, Koray Gursoy, Ugur Kocer
DOI:10.4103/tjps.tjps_97_18  
Avulsion injuries involving upper extremity are challenging in most cases. The musculoskeletal and main neurovascular parts on the injured region are unharmed. Even though the hand functions are maintained well, it is difficult to reconstruct large areas of defective skin. This specific case report demonstrates the mesh autograft methodology to successfully reconstruct the skin loss after a forearm skin avulsion injury.
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Lipofibromatous hamartoma in median nerve: A case report and review of the literature p. 214
Hojjat Molaei, Omid Etemad, Ali Yavari
DOI:10.4103/tjps.tjps_16_19  
Lipofibromatous hamartoma is a rare fibro-fatty tumor. This capsulated tumor contains no neural elements. Lipofibroma acts like a benign tumor and may not show any activity for many years. Until 2010, only 88 cases are reported in the literatures. Here, we reported a 33-year-old male with a 10 mm × 30 mm × 40 mm lipofibromatous hamartoma in his left palm. All symptoms disappeared after the surgery.
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Repairment of lateral malleol defects with distal pedicled peroneus brevis muscle flap p. 217
Serhat Yarar, Munur Selcuk Kendir, Zeynep Altuntas
DOI:10.4103/tjps.tjps_90_18  
The availability of local tissue in distal 1/3 of the leg and around the ankle is limited, and the difficulty in re-establishing soft-tissue coverage for these defects continues to challenge surgical procedures. In this study, two cases who had the soft-tissue defects around the lateral malleol reconstructed with the distally pedicled peroneus brevis muscle flap were discussed. The first case was a 30-year-old male patient, who had 4 cm × 2 cm soft-tissue defect with bony exposure, inferior to the lateral malleol after a gunshot injury. The second case was a 26-year-old male patient who had 5 cm × 3 cm soft-tissue defect with exposed metal implant, distal to the lateral malleolus after a traffic accident. Both of the patients were quite satisfied with the esthetic results. The distal pedicled peroneus brevis muscle flap should be kept in mind as a reliable and relatively easy flap option for the reconstruction of the soft-tissue defects around the lateral malleol with good results.
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LETTER TO THE EDITOR Top

Nasal tip avulsion due to dog bite p. 220
Nilufer Bahadirli, Suphi Bahadirli, Mustafa Keskin
DOI:10.4103/tjps.tjps_3_19  
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